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MURDOCH RESEARCH REPOSITORY
This is the published version of the work, including publisher’s layout and pagination.
The definitive version is available at
http://dx.doi.org/10.1016/j.erap.2012.08.001
Ho, M.S.K. and Lee, C.W. (2012) Cognitive behaviour therapy versus eye movement desensitization and reprocessing for post-
traumatic disorder–is it all in the homework then? Revue Européenne de Psychologie Appliquée/European Review of
homework compliance and treatment outcomes. Furthermore in studies which have used
CBT-based approaches with trauma populations and there have been no homework tasks, the
experimental group reported more physical symptoms (Batten, Follette, Rasmussen Hall, &
Palm, 2002), and more health care visits and avoidance symptoms than the control group at
follow-up (Gidron, Peri, Connolly, & Shalev, 1996). It appears that homework is required in
CBT-based approaches as consolidation is not completed in-session and requires extra self-
guided tasks to promote habituation (Dozois, 2010).
Compliance rates for homework completion are low in most clinical populations and PTSD
groups are no exception (Shapiro, 2001). Scott and Stradling (1997) report that only 7% of
participants completed their homework in the prescribed manner in the IHT group and 56%
of participants fulfilled the homework requirements in the PE group. The authors observed
that the participants with more severe symptoms and co-morbid depression were less likely to
comply with homework tasks. This is concerning as CBT-based approaches are not as
successful without a homework component (Kazantzis & Lampropoulos, 2002) and this may
be especially so for clients with a trauma history (Baikie & Wilhelm, 2005). As a
consequence, even though CBT is efficacious for PTSD patients it may not be the most
appropriate treatment (Scott & Stradling, 1997).
Thus, if homework is an unnecessary component of EMDR and it is equivalent to TFCBT
then there is an efficiency argument in favour of EMDR. This was highlighted in the current
data by the difference in prescribed homework between the two treatments and the
calculation of an effective size per hour.
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A major controversy remains when considering the treatment of choice for PTSD. To date we
still have no clear understanding on the role of eye movements in the treatment process. It is
possible that the eye movements promote an orienting response to the trauma by allowing the
patient to confront the memory which becomes less threatening as the patient has to divide
their attention between a motor task and the task of holding the visualisation of the trauma in
their memory. That is, initially the traumatic memory may be upsetting and cause the person
to initiate a “what-is-it” reflex. When there is no imminent threat, the patient’s sympathetic
nervous system responds accordingly. A recent study by Schubert, Lee and Drummond
(2010) confirmed this by measuring autonomic changes experienced by a non-clinical sample
randomly assigned to a single session of EMDR with (fixed or varied pace) or without eye
movements. They found that EMDR with eye movements was not only associated with
reduction in distress over negative memories but also significant decreases in heart rate at the
onset and skin conductance during eye movement sets. This relaxation response (which is
incompatible with anxiety) is paired with the traumatic memory which reduces avoidance and
allows the memory to be processed sufficiently. The relaxation response primed by the eye
movements in EMDR is clinically meaningful as it may moderate arousal during treatment.
Thus, EMDR may be particularly apt for patients who are unable to tolerate the distress
caused by exposure and who are unlikely to engage in homework tasks for the same reasons.
An alternative to the orienting response is that to store trauma memories in an episodic form
taxes working memory and that eye movements competes with such memories for the limited
storage capacity which then results in reductions in vividness and subsequently emotional
ratings (I. M. Engelhard, M. A. van den Hout, & M. A. M. Smeets, 2011; van den Hout et al.,
2011; van den Hout et al., 2010)
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EMDR is efficacious for PTSD and trauma patients with or without co-morbid depression
and requires little –to- no between session tasks to ensure positive outcomes. This evidence
can be added to the growing list of differences between EMDR and CBT that others have also
noted including the way exposure is employed in each of the 2 treatment modalities, EMDR’s
non-directive approach, and the encouragement of free association during trauma recall and
distancing. Despite these differences it is still not clear as to why homework is not required
and what mechanisms are behind EMDR’s observed efficiency. Further exploration of this
area may help to identify relevant treatment mechanisms .
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